Clinical Documentation
February 9, 2022

Clinical documentation cheat sheet

Clinical documentation cheat sheet

What is clinical documentation in healthcare?

Clinical documentation refers to the creation of medical records that pertain to patient healthcare. These documents may contain information concerning symptoms, diagnosis, assessment, treatment, as well as any testing. While there is no straightforward or universal standard when it comes to clinical documents, they are used by over 90% of health practitioners in the US and provide relevant insight concerning the patient health experience. Additionally, clinical documents serve as excellent points of reference to improve your future treatments, as well as being rewarding summaries for other healthcare professionals to refer to. Because of their accessible format, they can be easily understood by most health users, and with one glance, practitioners can have an insight into patient treatment. In the case of a lawsuit, clinical documents also serve as sufficient medical reasoning and credit your practice with authority and reputability. 

clinical documentation in healthcare

Fundamental reasons for good clinical documentation

Clinical documentation is essential for a multitude of reasons, and as the healthcare industry is constantly changing and adapting, it is critical that your practice makes efforts to produce high quality documentation. It ensures patient data is up-to-date, and that all relevant information is stored for reference and future contribution to effective treatments. There are numerous advantages that will result from improving your clinical documentation, including:

  • Good communication - Documentation outlines all points of interaction between practitioners and patients, and with their concise format, all healthcare professionals should be able to understand a patient’s health state. Clinicians should be able to easily pick up on a client’s health condition from the information listed on the document.
  • Ensures reimbursement - Good clinical documentation is the key to appropriate medical billing and coding processes. You can ensure that the relevant medical equipment and services are billed and coded for, and as a result, your insurance claims are accurate and more likely to be accepted.
  • Reduces malpractice - Clinical documentation ensures that you are HIPAA compliant and have medical reasoning behind all your treatment decisions. For example, documents can support you against any claims or potential lawsuits. 

The basics of clinical documentation

Despite every healthcare practice conducting clinical documents differently, there is a basic structure that you should adhere to, in order to receive the highest level of care for your patients. You should be incorporating the following features to elevate the quality of your notes:

  • Include date and times - In order to properly piece together information, it is important that you document the time and date on each patient note. 
  • Write signatures - You need to sign each page of client information, as well as write your name and role on any documented interaction. This ensures individuals know who is attending to certain patients, and in the case of legal issues, who is responsible. 
  • Make timely entries - Make sure that you compose entries in a timely manner, so you can avoid missing out on critical information. It is equally important to not write them during your sessions, as this can interfere with your client and be perceived as rude.
  • Be legible - Because other healthcare professionals are reading through your documents, they should be typed electronically in order to avoid miscommunication. If they are handwritten, extra care needs to be taken to ensure they are legible and clear. 
  • Avoid abbreviations - Unless they are universal, it is best to avoid abbreviations so you can minimize the risk of misconstrued information. 
basics of clinical documentation

Tips for effective clinical documentation

To really hone in on what makes clinical documentation effective, there are numerous strategies you should implement to elevate the quality of your service. Doing so will increase patient satisfaction and improve the daily operations of your practice

  • Report critical values - Remember to always report critical values to a nurse within 15 minutes of the data being verified by the lab. Failure to do so can delay treatment, which is detrimental to the patient. They should also be reported to physicians within 30 minutes.
  • Avoid general information and statements - Each clinical document needs to be specific to the patient, and any general statements can easily be misconstrued. For example, simply stating that the patient called is inadequate, and you need to specify whether the patient needs a return call, or if they have a concern or query.
  • Accommodate your busy times - Even in your busiest time of day, you need to be aware of critical codes and transfers, changes of shifts, and different medication and physician orders. Despite how large your load is, you should not miss these vital details. 
  • Correct documentation methods - Your documents should be highly accurate of the patient experience, and composed in a legible format so any healthcare professional can pick them up and understand the patient’s condition. They should also contain the subjective perspective of patient symptoms, as well as objective observations. All notes should be in a professional manner using correct spelling, grammar, and tone, and without any personal judgment.
  • Correct notes - Any allergies or medications should be listed, as well as late entries and corrections. 
  • Efficient charting procedures - No charting should ever be completed in advance, and these will be reviewed in addition to flow sheets. Patient assessment must be carefully documented, and with the right nursing policies consulted, these should elevate the quality of your notes. 
Tips for effective clinical documentation

Clinical documentation examples

To help illustrate the importance of clinical documentation, it is important to see practical applications of clinical notes in the healthcare workspace. 

Further reading:

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